 Welcome to the this week's edition of our noon interdisciplinary conference, and it is an honor for me to introduce our speaker today who is well known to many of us here at the University of Chicago. Dr Monica peak is the LNH block professor of health justice at the University of Chicago and also an associate director of the McLean Center. Dr peak is a graduate of Johns Hopkins medical school and completed residency at Stanford has been on the faculty now for how many years Monica I've lost track a while, a while. So, Dr peaks research pursues health equity and social justice with a focus on promoting equitable doctor patient relationships among racial minorities integrating the medical and social needs of patients and addressing health care discrimination and structural racism that impact health outcomes, specifically for example diabetes and COVID-19. Dr peak has authored over 150 here reviewed papers has served as principal investigator for multiple grants from institutions such as NID DK NHL BI PCORI AHR Q and the Robert Wood Johnson Foundation along with Greenwall Foundation, the Merck Foundation, among others. In addition to being the associate director of the McLean Center, Dr peak is associate director of the Chicago Center for diabetes translational research, the executive medical director of community health innovation. And she is a senior associate editor for the journal health services research and a member of the National Academy of Medicine. So today by Dr peak will speak on clinical medical ethics and human rights. Welcome Monica. Super excited to be here. Thank you all for coming out with it being like three degrees. So, so yeah today I'm hoping that we can have a bit of a discussion if possible so I'm going to talk, but I'm I've thrown a couple of slides with some questions that hopefully we can either address in real time and then I have them sort of again at the end and I'm technically challenged so we'll see how this goes. I'm supposed to lean into the microphone also already getting challenged. So simple. Okay, um, so just always like to start by giving a thank you to all the places I sit on campus. But today I am also representing physicians for human rights. So that's an organization for the past year. I've been on the board of directors and previous to that I was on the physician advisory council. And so I say that because for all for lots of reasons, one of which many of the slides have come from Michelle Heisler, who is the current medical director Michelle is like one of us. She is a clinician she's an internal medicine physician she's a health researcher. And like myself a lot of her work had previously been in diabetes but she'd always had a passion for human rights particularly international human rights and so she still works at the University of Michigan, but spends a lot of her time in New York City. I'm being the medical director for physicians for human rights. And so she's brought some of her friends to be on the board, which even though it's a physicians for human rights organization because a lot of our work has to do with legal issues. Many of our board members are lawyers and our current chair is a lawyer and also has a PhD. And I also just wanted to give a shout out to Dr. Robert Lawrence, who is one of the founding members is currently a board member emeritus and a past board chair and I met him. I think in like night before 2000, many years ago. And he's just been so generous with his time such a dedicated servant to social justice, and it's really been an honor to work with him. Again. All right, let's see here. So today is my roadmap. I'm going to talk briefly about clinical medical ethics, because you guys are here so I have to elaborate on that health and human rights physicians and human rights, and then sort of walk through for sort of case studies about some of the work that was done. And then have us think together about the implications for what we as clinical medical ethicists might do what our role might be, etc. So you'll sort of see what I'm talking about. All right, so I always have these slides of my talks just to reorient myself and everyone else who might be watching or listening, which hopefully is all of you. So clinical medical ethics is a medical field that helps patients, families and health professionals reach good clinical decisions by taking into account the medical details of the situation, the patient's personal preferences, values, socio economic considerations and ethical concerns. It examines practical ethical concerns that arise routinely and encounters among patients, families, healthcare professionals and healthcare institutions. There are four key ethical principles that have beneficence. So, you know, doing good, maximizing a patient's well well being in health, non maleficence. Do no harm, reducing or avoiding patient harm autonomy respecting our respect for patients ability to make decisions for themselves, and then justice. And we sort of define that in ethics as ensuring fairness. And so we'll talk a bit about what that might look like. So then thinking about human rights. And we think that they are inherent to all human beings. So human being, regardless of who you are, where you sit, how you represent yourself, a universal human right. And there's a range of fundamental protections, the right to life, the right to be free from torture and ill treatment. Some of these are positive rights, so the right to necessary that are necessary for a dignified life like health, housing education. And some of them have been sort of codified into laws or covenants or treaties conventions etc. So then they can become can become enforceable or there's some accountable agency or body. And there are connections between health and human rights. And so this is sort of a been diagram, because some human rights may have a direct implication for your health. I'd say almost all of them do, but some may have less of a direct impact on your health. So what is unique in our role as physicians, because a lot of people who think about human rights aren't physicians. Many of them are lawyers are social scientists are, you know, case workers. Just many people come to the field of human rights who aren't physicians. So what do we have that is unique to offer. And so a lot of times we have a different kind of moral high ground or ethical high ground that we can sit upon which is why I'm talking about it here in this context. But we also are trained as clinicians and so we actually have skills and tools that can be applied to patients in need whose health has been harmed. So we have the clinical expertise and the use of scientific evidence to document violations of human rights and their health effects. And so many of you may think of physicians for human rights and like, oh, that's the group that does like physician asylum cases a lot. And I actually spent a good bit of my time consider my life as many of you might sort of pre children and post children so much. Or when I had free time and when I no longer have free time. And so pre kids, I did a lot of human rights asylum cases for pH are before I sort of joined officially as the organization and leadership. We have the perception of having objectivity rigor and credibility. Our profession is guided by professional ethical obligations. We have specific training to assess and a seek to assess and seek methods to alleviate pain and suffering. We're often at the front lines where we can witness health harms from violations, particularly free are working in urgent or emergent care situations. And if we have chosen to volunteer to travel abroad and work, particularly in areas of conflict or war, or just in areas that are in natural disasters areas just need because of structural violence. You know, an absence of a lot of infrastructure. And, you know, some of the things that I was just mentioning the right to water, you know, clean water housing, etc, where there may be less of that. And we actually don't even have to leave the country to experience those things we have those conditions in this country. But every country has a tendency to not really have the ability to look internally to look fully at itself and see our own limitations. We like to go abroad and see other people's limitations. And so, so many of the challenges that we can more clearly see in other countries we have right here at home that we could be addressing. What do you have as physicians the influence and reputation of being the good doctor. And the internet we have the international language of, you know, Dr. speak, which is its own language and communication, and then we have an international community that can be mobilized we're using the same skills and tools and actually just last week or two weeks I had an email from our Dean Vinnie Aurora, someone had reached out to her from Stanford, and someone had reached out to him from an area of conflict in the world. And so they were friends, he knew Vinnie, and he said I'm assuming you know Monica peak, because she's on the board of phr. I'm trying to get a message from this person around the world. And so we're an international small community, and that's uniquely connected. So physicians for human rights, we work at the intersection of medicine, science. That's blocked over there to and justice as a secure human rights and justice for all. So we were founded in 1986 by a group of physicians. And this guy here is Bob Lawrence, the one over here to my point my ability. I'm geographically challenges guy in the corner. So he was I wanted again the founding member. So health professionals with their specialized skills their ethical duties and credible voices, who have been uniquely positioned to stop human rights violations. And it really, really has been an honor this past year to move to the board of directors and see firsthand the reports as they're about to be launched, the amount of work that has gone into them, and to sometimes be involved in them before and just the magnitude, the dedication. It's really it's been crazy. It's incredible, the amount of work that we're doing and how effective we've been able to be in lots of spaces and places. So we work to investigate and document the health effects of human rights violations to amplify the voices of survivors and witnesses, and to provide evidence to ensure that perpetrators are held accountable. We collaborate with hundreds of partners around the world, we could not do the work without lots of places on the ground, people whose lives are literally at stake. And we have had multiple times when there were people who were conferencing in. And I'm just going to just say this upfront anyone who see me talk. There's a 75% chance you've seen me start crying. It's like my feelings are just like always right here. So that probably what I'm realizing I'm about to have that happen right now and I'm just like getting started. So just a heads up warning. But many times we've had people who have conferenced in, and they have been in secret locations where they could not even tell us where they were, because their life would be harmed in harm's way. But they were doing such important work that it was critical that they still be involved in documenting the things that were happening. And so we are privileged to be sort of a large national and international banner. But there's absolutely no way that we could do our work without people who have literally sacrificed their lives to make sure that the work is done. So we have lots of sort of key issue areas. And the methods that we use to defend and document human rights and I list them here because these are things that are skills that you may think I have these skills. Medical assessments. I can read x rays and I can review medical records. I know how to do cross sectional population based surveys and do systematic reviews. These are not things that are unfamiliar to anyone in this audience. They're the bread and butter of clinicians of clinician investigators. You know, they're, they're what we do. It's why Michelle who is basically my clone, as far as her skill set is the medical director of PHR. And so I say this to encourage all of us, you know, who are ethicists. So that's an extra level of training to consider expanding how you see yourself as an ethicist in the world into the world of human rights. So this is again, sort of our, our, the categories of work that we that we do a role of documenting torture and ill treatment. I'm supporting claims for political asylum, a role in providing medical care for all without discrimination and the role in documenting attacks on health care workers and health systems and a role for health professionals and documenting finding what's what we call dual loyalty. And so that maybe obviously may not we're going to have two of our case studies going to be in that space. These are obviously not mutually exclusive categories. And so some of our cases are, are in two categories and we'll talk about those. So we're going to jump right in. So, I bring this up because many people. And that's how I had always thought about it is that think about human rights violations as things that primarily happen in international countries, other places. And certainly that changed with Guantanamo. So generally we think about all of these horrors is not really happening here in the US. So we had a report that came out within the past year about not within the past year, obviously because Trump's president. So, like my sense of time is all fluid. But I said the past year because I want them the board of directors of past year within the past several years. And we were still under the Trump administration. So I was on an advisory board then about people who are being separated at the border. And so, HR analyzed 31 medical legal affidavits of parents and children up to a year after experiencing their separation. And all continue to show symptoms of PTSD, depression and or anxiety, stemming from that single traumatic episode of the forcible separation. In all of the cases, the governments, our government's actions met the legal standards for torture. So discriminatory actions that cost severe pain and suffering with the intent to punish, coerce and intimidate asylum seekers to give up their claims to and to defer future asylum seekers. So one person said every night I would go to bed alone, I was sad, and I would cry to myself. And this was a six year old girl from Guatemala who said she felt abandoned after being separated from her mother. So this is just a picture of a shelter for migrants in Tijuana, Mexico. And so in this case, all of the asylum seekers interviewed described gratuitously cruel, gratuitously cruel and inhumane treatment at the hands of the US government, including physical and verbal abuse by US officials in humane detention conditions, active deception about their expulsion and whereabouts of their family members and whereabouts of their family members active deception and unsafe returns that put people at heightened risk of harm. So putting purposely returning people into harm's way when they know when they have just divulged where harm's way is. And so this was a report in July of 2021, neither safety nor health. So how the title 42 expulsions harm health and violate rights. The use of clinical and health knowledge to document and denounce poor health conditions in US immigration detention centers so praying for hand soap and masks. So just how few there were in the detention centers and how that contributed to the spread of COVID during the pandemic. And so this was just a panel. I did a bunch of panels from the pandemic. Just about lots of different things, COVID sparrows, etc. And this is one of the panels that they had about COVID in detention conditions. And we know that congregate living is a huge risk factor for the spread of COVID. And in our country, we tended to prioritize the elderly who were also at high risk. But the elderly living in nursing homes or other kinds of congregate living. And we had a really difficult time thinking about people who were in jails or prisons or detention centers because of our country's inability to put public health and public risk ahead of our social commitment to thinking about worthiness and punishment. And so many, despite recommendations, many people who are in congregate living and who should have gotten vaccinated did not. Many people who are in congregate living did not receive appropriate masking and the rates of death within prisons and jails was exorbitantly high. And there, I'm not sure if anybody saw pictures of their signs that people had on the outside of their jail cells like we're dying in here, please let us live, you know, etc. And then there was a study by a former medical student here about the impact of jail cycling on COVID in our communities here in Chicago where people were the over policing in our community was leading to people getting arrested, but not on things that would lead them to be arrested and kept in jail for a long period of time or in prison just temporarily for like things like protesting Black Lives Matter. So they would be arrested, their masks were taken away, they would be exposed to COVID, they'd be released into the neighborhood, COVID would spread. And so the magnitude of the effect size of that jail recycling was a larger contributor to COVID disparities than almost any of the other disparities that were being measured here in our city in Cook County jail. Immigration detention, these kinds of things. So what is our role as clinicians? Do we provide substandard medical care and be complicit within these systems? Do we just refuse to participate unless the standards are improved? And this is this kind of question are ones that have been analogous throughout history for physicians. We think about the death penalty cases and how they're continuously being botched, you know, your patients who've been, you know, paralyzed but there's still a wait because they can't figure out how to get the medicines right or, you know, all the way back to, you know, Nazi Germany, you know, and the physicians that were complicit there. And so how do we as healthcare professionals decide are we going to go into this horrible system and try and make it just a little better? Or do we say no, we're not going to participate at all until there's no system? You know, you can't do this because you clearly don't know what you're doing unless you're doing, you know, things differently. And so that's that's a question I want to throw out to the group. What is our role as clinical medical ethicists? And so when I say that I sort of think institutionally because, you know, seeing patients, how do our roles change from just merely a provider of care? And how do we interpret beneficence and non-maleficence for patients in this situation where you're trying to do no harm or maximize patient benefit for people who are in detention centers? And that sort of is getting back to that same question I was just asking. And does patient autonomy even exist for people who are living in these conditions? And then what is our role as global ethicists? And meaning that is clinical medical ethics something that we even do outside of our institution? Is that something only for patients for whom we have direct clinical care? I would say obviously not, but it's something that I want us to challenge ourselves to think about. So next I'm going to talk about attacks on the role in documenting attacks on health care workers and systems. And I'm going to use Ukraine because we published a study on that report on that about almost exactly a year ago. And that was looking at the attacks that had happened over a period of a year. And so it was about the start of the war for a year. And this was research that was done in collaboration with a number of other organizations. And these were some of the people that were in hiding when they were coming to meetings or would be on TV, but from undisclosed locations, etc. They were just incredibly, incredibly brave people. And so for that first year, well, up until like the end of December of 2022, these were the number of healthcare facilities and attacks that were taking place in that country. And so it's the attacks on healthcare were a daily feature during the first weeks of the full scale Russian invasion of Ukraine. And for 35 days, healthcare was attacked every single day between February 24th and the end of December, which is where I showed you that map. There was an average of more than two attacks on healthcare each day. So they were really trying to cripple the healthcare system. And so that was one of the strategies of war, the active strategies of war. And so these are just some scenes that some of the hospital workers and medical personnel took. And so obviously the tax diminished diminished access to care reduced vaccinations rate back and vaccination rates were in the middle of the pandemic when this was occurring, diminished the ability to monitor to manage chronic disease and increased financial barriers. As of December of 2022. So right before the report came out almost one fifth of Ukraine's population reported insufficient access to healthcare services and medication. Obviously the war is still ongoing. These numbers have only worsened. And so one of the things that PHR with has been trying to do, and particularly with the report was to try and make the case at the Hague for accountability for war crimes and crimes against humanity. Using the international criminal court, Ukrainian criminal law, universal jurisdiction, and the UN independent international commission of inquiry. So using multiple different legal mechanisms around the world, but to try and make this case. And so in addition to the report to being, you know, on multiple, multiple media venues. Michelle as an clinician investigator has also been really instrumental in tapping into the medical literature. And so this is an editorial in the BMJ. So things in JAMA, the Lancet and the Lancet has always been much more progressive and sort of thinking about sociopolitical factors that impact health. And so it's been great partners. I will say that there has been a lot of controversy about what's happening in Gaza. And so I'll just note that on October 13th, PHR made a statement about the attacks by Hamas. And in October 17th, it made a statement about the impact of what was happening on the devastating hospital strikes. And so while I'm not allowed to sort of comment on current ongoing things that we're doing until they're, you know, published, I will say that we believe that war and victims of war, that war is a public health issue, and that victims of war are our people that deserve medical attention. So war and conflict, what is our role as clinicians, when and how do we decide to provide humanitarian medical aid to victims of international war. What is our role as clinical medical ethics, as ethicists institutionally, do we have one for war that's outside of our US borders. And then what are our role as global ethicists. What are the opportunities to use our skills as ethicists health services researchers and thought leaders to impact the global narrative that's that happens and, you know, there's war raging the time across the globe. All the time. So then I'm going to talk about two cases of dual loyalty, and I use these because they're ones where we have been doing work here at home, which is really important for lots of reasons, but also to highlight that mirror for our ability to take a deeper look at ourselves. Right. And to see what is happening here at home, and not just always be the warrior abroad. So, what is dual loyalty. It's when health professionals find their obligations to their patients, or what we owe to our patients and direct conflict with their obligations to a third party that holds authority over them. So your boss. So, here, even though I didn't talk about it in that way, because I said, you know, that their multis are not mutually exclusive categories, but the challenges of providing for health professionals and providing care to immigration detainees. So the first case or situation involves dual loyalty, and also the provision of medical care for all without discrimination. I'm going to let you guys ponder what I'm getting ready to talk about. So it's the excited delirium and police deaths or deaths in police custody. Raise your hand if you've heard of the term excited delirium. Okay, so you held your hand the longest. I know you're like me, what. Why did your eyebrows go up in shock and horror. Do you want to, and you don't have to, because I just appreciate you volunteering to like, yeah. But if you feel comfortable. Do you want to share what excited delirium means or what you've heard about it. And you can, you can check your head now. So I'm going to say what I thought I heard you say, and you nod your head if that was correct, that there's sort of an autonomic hyper reactivity, sort of delirium that can lead to death in circumstances that might otherwise not. And that there's some controversy around it. And maybe something else. Okay, that is exactly right. And it sounds kind of nutty because it is nutty. But it's the I so. So I'm going to I'm going to walk you through, I'm going to walk us through all of that. So these are people who were claimed to have died from excited delirium. And the ultimate finding from our report was that it's not a valid independent medical or psychiatric diagnosis and should be not should not be used as a cause of death. So, what methods did pHR use in sort of making this determination. Ones that we all have, we reviewed the literature, we read, you know, documents and we interviewed people. Right. These are not things that you all are unfamiliar with. So the origins of excited delirium just sound too ridiculous to be true but they are. They started in 1990, where the Miami Herald had whether there's some deaths of black women. And when we think about the intersectionality, which is people who have multiple marginalized social identities, the more that you have the higher your risk of poor health and you know being pushed to the, you know, the most extreme margins where society cares the least about you and is willing to come up with all these reasons why somehow you're to blame for these bad things happening to you, rather than structural things being in play. So black women were dying, and there's not a lot of societal worth for black women. So rather than saying maybe they're being murdered. Like, no, that can't be happening. For some reason, who black and black women were dying but there are also some men. And so they're saying for some reason the male of the species, as though black people are different species, become psychotic, some reason. The female species dies in relation to sex. So the autopsy so these are forensic pathologists have conclusively shown that these women were not murdered 70% of people dying of coke induced delirium are black males, even though most users are white says the deputy chief medical examiner, why it may be genetic. So the, the hypothesis was that people were taking cocaine and getting so delirious that they would just spontaneously die. And that the women, when they had sex, while they were having cocaine with spontaneously die for genetic reasons, of course. So, so this was like okay this theory was was starting to make its way around. Then there was a book published called the excited delirium syndrome, and then taser bought 1000 copies of that book and start distributing it to forensic pathologists. And then scoring the ethical harms of the mismatch of getting into bed with industry, and in what that can possibly mean. And then as a sort of takes off. And in 2009, there's a white paper that was published by the American College of emergency physicians. And it's the consensus of the task force that excited delirium is the unique syndrome, which may be identified by the presence of a distinctive group of clinical and behavioral characteristics that can be recognized in the pre mortem state. Excited delirium while potentially fatal may be amenable to early therapeutic intervention in some cases. So then it becomes medicalized. It's used and diagnosed almost exclusively by police in the pre mortem state. That means during police custody. And they'll say that this man has excited delirium. What he's doing is fighting for his life. But because he's resisting. He's delirious. And we have to apply more force to suppress him. And that happened to many black men and police custody. It happened to George Floyd. And it happened to others. But during that time of 2020 was a time of racial reckoning around state based violence. And a lot of publicity around that. And people like what exactly is this excited delirium business. What's what's going on with that. People start asking questions. And so this delirium is frequently asserted as a as a defense by police officers who kill people during the course of restraint. But it can't be disentangled from its racist and unscientific origins. Yes, state medical examiners have listed this as a cause of death. And police have been exonerated on this diagnosis. In June of 2021, the American Medical Association, which just has this horrible history as we all know, but they have been like coming into, you know, the real world, right. So they've had a lot of good people join their team. They have been trying to do right for a while now, you know, I've joined the AMA again. So they officially announced a policy that opposed excited delirium as a diagnosis, the ACEP in 2021, put out a white paper. And then in case you missed it in 2023 said just to say again, retracting that statement from 2009. And our report, you know, came out. And this was just in October. When I was in DC, we found out that the governor and California banned excited delirium as a cause of death. And you all can say this, this makes no sense at all. It is now against the law in the state of California for people to use excited delirium. And they attribute or that they comment about the American Medical Association and the first person they quote is Dr. Heisler, our medical director, who is one of us from phr. So state based violence. And that is what police killings are, or state based violence. What is our role as clinicians. And then particularly in the setting of this strange history that started in the 80s hasn't really ended but is starting to unravel. How routinely of excited delirium, how routinely do we challenge diagnosis from other specialties that we may not be fully aware of few people in the room had even heard of excited delirium. I hadn't heard of it until I helped with the report to come out. If I had heard of something, you know, I'm an internal medicine physician, I get patients from the ER, we admit from the ER, I guess. I guess that's probably the point is these patients would have died in the ER or died in police custody I probably this why I never see that. But a bit just in general, you know, how often if, you know, if we have heard a term. It's something that has been diagnosed in another specialty. Would we say, Oh, that's, that's the realm of that specialty. I'm not quite sure I know what that is, but they're the experts. I'm going to take that, and just add it to my list of diagnoses, as opposed to saying, that sounds strange. Like, what happened here, maybe I shouldn't use my own investigation. Yeah, so that's one thing I challenge us all to do. How do we provide care for patients that are incarcerated. Thank you Megan. What is our role as clinical medical ethics, at this point say ethics, ethicists. How do we bring in and validate the historical and contextual experience of patients lives into the clinical encounter. How do we do that in a way because so often we people are telling us what has happened. But we have some official record from the ambulance driver there may be a police report as to what actually happened there may be some other something transfer document something that's the real story. We may invalidate what patients are trying to tell us. How do we learn to listen to what people are trying to tell us the state based violence that has been happening. Has been happening. For decades for hundreds of years. What is different now is that we all have cell phones. And we were able to document that. But black people have been saying this, all of this time. All of this time, and police have been saying, no, no, no, I saw a gun. He was coming at me. There's a reason that I was frightened, but he has 3000 bullets in his body, you know, there are 10 police and turns out he just had a butter knife. I was so frightened, you know, like the stories have frequently not made sense. But we've made them make sense to us. As we have not valued the lived experience and the, and the words of marginalized people who are coming in and telling us something compared to the powerful words and stories of those who have more power. How do we learn to engage in a way that's more meaningful. When we're sharing in decisions. Which parties are we sharing in. How do we bring in the ethical principle of justice. And how are we defining justice in this in this way. We think about our role as global ethicists. How have we, because everyone has been woke, although now we're like, oh, should we be both to black lives matter. After this, right. And everyone wanted to, you know, do something be more aware. But have we actively been involved in efforts to change the circumstances in which we have, you know, see black people getting killed every every day and it's like no, no, it's just not even noteworthy here about it on the news. Have we been involved in social justice movements that challenge state violence against the black community. And the last one is sort of an alignment between dual loyalty and attacks on health care workers and systems, although I'm not going to talk about the health care worker attacks. I don't have any slides about it, but we know this to be true. And that has to do with providers of abortion care. So, this is an issue that is here in our country that we have taken on as a human rights issue. Following the United States Supreme Court decision in Dobbs versus Jackson women's health organization in June of 22 people in the US who can become pregnant are facing an unprecedented human rights crisis. In Dobbs the Supreme Court overturned the constitutionally protected right to access abortion, leaving the question of whether and how to regulate abortion to individual states. Approximately 22 million women and girls reproductive age in the US. The number has risen now live in states where abortion access is heavily restricted and often totally accessible. And then this briefing details the intense fine human rights emergency caused by this decision discusses ways that Dobbs contravenes the US international rights human human rights obligations. There's also a study. It says embargo embargo but it's not. This was out last year called no one could say where members of phr called around in Oklahoma, which already is a desert for gyn care. And was asking, could anybody tell them what the policies were for accessing emergency obstetric care, you know what the rules were in light of Dobbs, like, you know, nobody could really say. That's why they titled it. Well, you know, they were getting referred to other people. I think it might be this but I'm not sure. Have you talked to, you know, no one in the entire state. I think it's a large state had a had a firm grasp on how this decision would be impacting their providers. Yet, there are laws in place that made this illegal. What are providers and patients to do many providers in states like that pack their bags and left, which meant that patients who are not even thinking about. Obstetric care don't have the women's health care they need. And many there's that there are providers who lived in surrounding states, but would go in to provide care just because it was, you know, healthcare shortage area. And so we are, you know, creating deficits for everyone. In sort of the short side of policy to keep some people from having access to certain kinds of women's health care. So criminal, the criminalization of abortion creates a dual loyalty challenge by preventing clinicians from meeting their professional obligations. You know, this, you know, I have this for my patient that I need to treat. I have professional standards, but then the law says, I could go to jail. You know, I could lose my license. In some places, you know, neighbors, I mean, so great neighbors could file suit and start arresting. It's the nuttiest thing. And so what are we to do. So Louisiana, so I hail from the south for better or worse. If you know me, I've probably hugged you and that's good. That's because I'm from the south. But, you know, the south is just known for all for mainly bad things. So Louisiana has the highest rate of maternal mortality amongst all the states, more than 58 deaths per 100,000 live births. And black women account for 39% of the women who gave birth in 2019, but 70% of maternal deaths, four times more likely than their white counterparts to experience pregnancy related death. And, you know, I have been talking to my daughter, who is 15, and telling her that all of my life, I've had the privilege of living in Rome, not all of my life, but most of my life. So I'm 54, you know, and so. But that, you know, it used to be a horrible world for women who had to make very difficult choices and many of them died. And that we're slowly turning back so many freedoms for people who don't have power, including women and racially minoritized people and immigrants, new arrivals, and I'm frightened for her and what her future looks like. So what is our role as clinicians here in Illinois? We have this little Oasis. How do we best support patients as Illinois increasingly becomes, you know, an Oasis for reproductive rights for women. Are we going to consider providing telehealth for out of state women. We had a lot of policies in place for us to do telehealth for our patients who lived out of state during the pandemic. And some of those restrictions were tightened back up. You know, what are we going to be thinking about trying to do for this emergency. For non-gynecologist like myself, how do we best support our gynecology colleagues. One of the things that are important, I think, is for everyone who's not a gynecologist to think about the impact that this has on their patients. For oncologists whose patients may be undergoing chemotherapy and get pregnant, you know, oncology is not just an old person's field, as far as patients. Everyone has some stake in the abortion situation, not just the providers who have to provide the abortions. But the brunt of the burden is on those colleagues. How do we work together to support them? What is our role as clinical medical ethicists? How does this ruling change perceptions about what's best for patients? How do we do no harm for patients? Clinically, socially, you know, there are some patients in some areas that are afraid to even tell their doctors that they're trying to get pregnant. Because what if that is in the chart and something happens later, they come to the emergency room, their family's with them. You know, there's all of this, like, who knows what my personal status is. How do physicians ourselves introduce into these decision-making equation about what to do for abortion? Previously, it's been all about the patient's well-being. Now we have to think about our own well-being. Am I going to get sued? Am I going to jail? Lose my license? Never seen my kids again? Like, when did that come into play? It's in play now. What are, again, the strategies in our toolkit to help shape the national narrative, the national policy to address some of these issues? So that's all I have. The same thanks again to all of the people who make this work possible. And then I have those, these sort of four case bullets again. What time is it, Peter? Okay, so I wanted to, like, not just have these be theoretical questions, but actually have us discuss them if we, and so we have 30 minutes when we have four. Which, well, do I want to do first? Or you can be like, you know what, it's cold outside and I don't feel like talking. Can we break it one? And that answers yes all such. Megan? Yes. Right. Exactly. Exactly. So I'm just going to summarize that. I missed Grand Rounds yesterday because I was on a campus elsewhere. And so, Harold Pollock was chastised for not repeating the audience things. You know, there's a lot of dead air in there. And I was like, okay, so note to self. So Megan's comment was that to horribly try and summarize just the idea of the moral injury involved when you try to think about withholding care for the best outcome. If you're only doing it by yourself or with a group, because there's usually some sort of work around of a group of physicians that will take on that job. And particularly because it is frequently institutionalized where the healthcare institution has decided to take on that job. And so then you're not just sort of freelancing but you're reporting directly to your boss who is saying we're going to do this work. And so it brings in additional challenges. And so, Matt Winnie, who works, used to work for the AMA used to be here faculty here he's now out in Colorado, had written a piece around reproductive health and it was suggesting that we all as physicians should like band together and say, you know, we are basically going to have like a moral protest together. And we're not going to abide by these federal laws, because they can't send us all to jail. Sort of the thinking of the civil rights movement like, you know, you can try and put you like we'll just keep, you know, like you can single one of us out. But you can't shut the entire medical profession down. And that's a challenge, because it is so easy to isolate us. And particularly like I said when there's one profession that is disproportionately bearing the brunt of it. Peter you had a comment. Yeah, thanks. Absolutely. Many of these slides come from a talk that Michelle gave to medical students. And I was like I was saying in my pre Children Day. I did a fair number of asylum cases that came through Chicago. And even though the cases were so black in my in my mind. What I'm doing is like, his story sounds horrible. He's got all these cars here on his body. That appears to be from, you know, like a cigarette burn just I'm just describing what this person is telling me and what I'm seeing as a doctor he's missing a leg. You know, the, the vaginal parts have been sewn together from, you know, like all this stuff, but having a physician document that, or be willing to show up in court. makes such a huge difference in whether or not that case is going to go forward or not. And I'm like, anybody can read and look and see I'm not doing it. I'm not using special advanced medical skills. You know, but the weight of just having an MD say that, say what any normal person on the street would say carries so much weight. I think this one, all of these are things everyone in the room already has skills doing, you know how to read, you know, you know how to do whatever. And so volunteering to do any of this work. You know, you don't necessarily have to ride an op ed, but so much work is needed to be done. And, you know, Michelle does a lot of her work with medical school medical student volunteers. If anyone, you know, wants to volunteer and do any of this, you know, work interviewing people like all this stuff is just work that needs to be done. You know, anybody can do it. And some of the, you know, those those panels and things, whatever your level of expertise is if you're an infectious disease specialist or whatever specialist, you know they ask people who are expert in that area, you know, as clinicians, or as experts or whatever you get, you know people get called. And so you don't have to be a human rights expert to be able to make contributions you don't have to be a world renowned ethicist to make contributions, and that's the point of this is that we already have the skills, we already have the skills. We just need to want to do it. Any other comments. Answers to any of these questions questions out there to the audience like have have you all as clinicians come across cases that weren't sort of more clearly within the clinical medical ethics box that we normally think about things that may be more like this. And it have you. And what, and what have you done with that. What do you think about that. Are you like, Oh, that's not my, you know, like, or, or do you try and squeeze it into the, what, what, I'm just curious people's experiences. The question is, can undergraduates help with some of this work. I believe so. Because, you know, medical students. They're not doctors. I mean, no offense into anybody who's listening or in the room. I mean, so, you know, and many of them don't have clinical experience. The ones who have the most time are the pre clinical students like this summer after their first year. So they're essentially kind of undergrads. So my my guess is that that would be yes. Say what. Thank you.